Medical questionnaire – Exposure to mycotoxins / mold Last Name(Required)First Name(Required)Date of Birth(Required) DD dash MM dash YYYY Please check all options that apply to you most of the time.Section 1 Swollen stomach or flatulence Nausea Prominent veins on the limbs Lower limb edema Heart palpitations Easy bruising Shortness of breath, hunger for air, or frequent yawning/sighing Episodic cough Easily irritated lungs White coated tongue Chronic sore throat Postnasal drip or frequent throat clearing Mouth sores Itchy or painful ear canals Ears seem blocked Recent/recurrent sinusitis Ability to smell sharp odors of mold Sneezing or persistent runny nose Blurred vision, frequent changes, or difficulty reading Floaters in your vision Dark circles under eyes Eye irritation Allergies/hay fever all year round Unexplained mood changes, anxiety or depression Dizziness, lightheadedness, or feeling drunk Headache Feeling of instability, unstable mind, overwhelm Slowed thinking or brain fog Sensitive to light, sound or touch Chemical sensitivities Bothered by labels and seams on clothing Anemia Persistent weight gain Increased thirst Worse symptoms after exercise Severe fatigue without explanation Sleeping troubles Symptoms worse after eating Unexplained change in digestion/intestines Recent change in appetite Craving carbs, sweets, or alcohol Overactive bladder Bladder infections Rash, redness Frequent infections or delayed recovery from a cold Increased body pain This field is hidden when viewing the formRésultat – Section 1This field is hidden when viewing the formScore – Section 1Section 2 The voice sounds nasal Frequent static shocks Severe histamine intolerance Non-obstructive sleep apnea Reacts poorly in spaces with mold Sensitivity to electromagnetic waves Migraines Difficulty thinking clearly or memory loss Confusion or disorientation Allergies are not well controlled by medications Chronic sinusitis Nosebleeds New or worsening ringing or ear pain Asthma or wheezing Chronic cough Burning lungs Rapid heartbeat episodes Chest pain Low platelet count Increased food sensitivities Frequent vomiting Irritable bowel or alternating constipation/diarrhea Digestive ulcer or blood in the stool Inflammatory bowel disease or celiac disease Fatty liver Liver pain or swelling Unexplained menstrual changes Bacterial vaginosis Pain or swelling of the kidneys Itchy or burning skin Peeling of the skin Raynaud’s syndrome Eczema or psoriasis Activation of the Epstein-Barr virus Slow reflexes Balance or coordination problems Easily injured joints New or worsened nerve pain, numbness, or tingling Muscle weakness or spasm This field is hidden when viewing the formRésultat – Section 2This field is hidden when viewing the formScore – Section 2Section 3 Current exposure to proven mold Previous exposure to a damp, moldy, or water-damaged building at any time in your life Documented mold allergy Abnormal reaction to medications or supplements Autism or sensory processing disorder Chronic fatigue syndrome Chronic inflammatory response syndrome (CIRS) or positive Shoemaker tests Sensation of an internal vibration Dysautonomia or postural tachycardia syndrome (PoTS) Dementia Daily use of a sinus spray, sinus prescription, or Neti pot Nasal polyps Sinus surgery at any time of your life Hearing Positive MARCoNS Oral thrush confirmed Asthma difficult to control with medication Lung scars or nodules Pulmonary edema Idiopathic pulmonary fibrosis Respiratory distress or idiopathic pneumonia Lung cancer Arrhythmia Coagulation abnormalities Arteriovenous abnormality Churg-Strauss syndrome Peanut allergy Cyclic vomiting syndrome Eosinophilic esophagitis Nonalcoholic steatohepatitis (NASH) Hepatocellular carcinoma or other liver cancer Infertility Chronic pelvic pain Interstitial cystitis History of kidney stones Reduced eGFR (renal glomerular filtration rate) IgA nephropathy, nephrotic syndrome, nephritis or other kidney disease Kidney cancer Recurrent yeast infections or fungal infections of the skin, including athlete’s foot, itching, or yeast vaginitis Erythema nodosum Nail fungus Autoimmunity Mast cell activation syndrome (MCAS) History of previous or current cancer diagnosis, not specified elsewhere than the places named above Aplastic anemia Sarcoidosis Hypermobility or Ehlers-Danlos syndrome Tremors or nervous tics Difficulty walking This field is hidden when viewing the formScore – Section 3This field is hidden when viewing the formTotal ScoreCAPTCHA
